Provider Demographics
NPI:1558793406
Name:SANDY LILLIE, PH.D.
Entity Type:Organization
Organization Name:SANDY LILLIE, PH.D.
Other - Org Name:SANDRA LILLIE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:650-368-5802
Mailing Address - Street 1:102 VAQUERO WAY
Mailing Address - Street 2:
Mailing Address - City:EMERALD HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3152
Mailing Address - Country:US
Mailing Address - Phone:650-368-5802
Mailing Address - Fax:650-568-9800
Practice Address - Street 1:102 VAQUERO WAY
Practice Address - Street 2:
Practice Address - City:EMERALD HILLS
Practice Address - State:CA
Practice Address - Zip Code:94062-3152
Practice Address - Country:US
Practice Address - Phone:650-368-5802
Practice Address - Fax:650-568-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8872103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8872OtherLICENSE